* Carefully evaluate (at presentation and over the course of time) glomerular filtration rate (GFR), potential hypoglycaemia risks (with particular care in the use of sulfonylureas or glinides), nutritional status, and presence of comorbidities/frailty.
** The HbA1c target values proposed are intended as safe objectives, limiting the risk of hypoglycaemia.
Choose the main feature of your T2DM patient:
Essential notes for correct use of the algorithm:
The following specifications apply in all interventional flowcharts:
1. Each flowchart refers to newly diagnosed patients and/or those who are not receiving anti-diabetic treatment.
For other cases, enter the algorithm at the level nearest to the patient’s characteristics and therapy.
2. Proposed HbA1c target values are intended as goals that must be pursed safely, to minimize the risk of hypoglycaemia.
3. In the presence of a tendency towards hypoglycaemia, sulphonylureas or glinides must not be considered as options.
4. At any stage, it is always possible to start insulin therapy, even temporarily, being particularly careful in cases where there is a risk of hypoglycaemia and carefully assessing the cost/benefit ratio in obese subjects.
5. At every level, pursuing the target body weight of the patient is recommended; in case of excess body weight, reducing initial body weight by 5-10% is indicated, or at least its stabilisation.
6. If an assessment indicates that a treatment can be reduced/simplified to meet a change in clinical needs, you can follow the algorithm backwards.
7. Suggestions about the use of various drug combinations are intended to be used in accordance with their respective summary of product characteristics, which are available from the European Medicines Agency.
BMI, body mass index; CKD-EPI, Chronic Kidney Disease Epidemiology Collaboration; CRF, chronic renal failure; DPP4, dipeptidyl peptidase-4; eGFR, estimated glomerular filtration rate; GLP1-R, glucagon-like peptide-1 receptor; HbA1c, haemoglobin A1c; IDF, International Diabetes Federation; LAR, long-acting release; q.d.; MDRD, Modification of Diet in Renal Disease; quaque die (every day); SGLT-2, sodium/glucose cotransporter 2; SMBG, self-monitoring of blood glucose.